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2013 Medicare Advantage Plan Details |
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| Plan Name: | BlueMedicare Regional PPO (Regional PPO) |
| Location (County, State ZIP): | Seminole, Florida |
| Plan ID: | R3332 - 001 Click to see other plans |
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Click here for the BlueMedicare Regional PPO (Regional PPO) enrollment options and to have a copy of this chart sent to your email.
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| — Plan Features — |
| Monthly Premium: | $0.00 |
| Monthly Premium with Low-Income Subsidy: | 100% | 75% | 50% | 25% |
| $0.00 | $0.00 | $0.00 | $0.00 |
| Annual Rx Deductible: | $0 |
| Health Plan Type: | Regional PPO |
Maximum Out-of-Pocket Limit
for Parts A & B (MOOP): | $5,900 |
| Gap Coverage: | No Gap Coverage |
| Total Number of Formulary Drugs: | 3663 Browse Plan Formulary |
| Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
— Cost-Sharing during
initial coverage phase: | $6.00 | $10.00 | $45.00 | $95.00 | 33% |
| — Number of Drugs per Tier: | 643 | 1072 | 355 | 1319 | 274 |
| Number of Members enrolled in this plan in your County: | 54,211 members |
| Plan’s Summary Star Rating: | 3.00 out of 5 Stars. |
| - Customer Service Rating: | 4 out of 5 Stars. |
| - Member Experience Rating: | 3 out of 5 Stars. |
| - Drug Cost Accuracy Rating: | 3 out of 5 Stars. |
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| — Plan Health Benefits — |
| ** Cost ** |
| Premium and Other Important Information |
| $0 monthly plan premium in addition to your monthly Medicare Part B premium. |
| Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. |
| Some physicians providers and suppliers that are out of a plan’s network (i.e. out-of-network) accept "assignment" from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept Medicare "assignment " your coinsurance can be based on the Medicare-approved amount plus an additional amount up to a higher Medicare "limiting charge." If you are a member of a plan that charges a copay for out-of-network physician services the higher Medicare "limiting charge" does not apply. See the publications Medicare You or Your Medicare Benefits available on www.medicare.gov for a full listing of benefits under Original Medicare as well as for explanations of the rules related to "assignment" and "limiting charges" that apply by benefit type. To find out if physicians and DME suppliers accept assignment or participate in Medicare visit www.medicare.go |
| $5 900 out-of-pocket limit for Medicare-covered services and select Non-Medicare Supplemental Services. Contact plan for details regarding Non-Medicare Supplemental Services covered under this limit. |
| $10 000 out-of-pocket limit for Medicare-covered services and select Non-Medicare Supplemental Services. Contact plan for details regarding Non-Medicare Supplemental Services covered under this limit. |
| $750 annual deductible. Contact the plan for services that apply. |
| Any annual service category deductible may count towards the plan level deductible if there is one. |
| $10 000 out-of-pocket limit for Medicare-covered services and select Non-Medicare Supplemental Services. Contact plan for details regarding Non-Medicare Supplemental Services covered under this limit. |
| ** Doctor and Hospital Choice ** |
| Doctor and Hospital Choice |
| No referral required for network doctors specialists and hospitals. |
| You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits. |
| Plan covers you when you travel in the U.S. or its territories. |
| ** Extra Benefits ** |
| Over-the-Counter Items |
| The plan does not cover Over-the-Counter items. |
| Transportation |
| This plan does not cover supplemental routine transportation. |
| ** Important Information ** |
| Premium and Other Important Information |
| $0 monthly plan premium in addition to your monthly Medicare Part B premium. |
| Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. |
| Some physicians providers and suppliers that are out of a plan’s network (i.e. out-of-network) accept "assignment" from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept Medicare "assignment " your coinsurance can be based on the Medicare-approved amount plus an additional amount up to a higher Medicare "limiting charge." If you are a member of a plan that charges a copay for out-of-network physician services the higher Medicare "limiting charge" does not apply. See the publications Medicare You or Your Medicare Benefits available on www.medicare.gov for a full listing of benefits under Original Medicare as well as for explanations of the rules related to "assignment" and "limiting charges" that apply by benefit type. To find out if physicians and DME suppliers accept assignment or participate in Medicare visit www.medicare.go |
| $5 900 out-of-pocket limit for Medicare-covered services and select Non-Medicare Supplemental Services. Contact plan for details regarding Non-Medicare Supplemental Services covered under this limit. |
| $10 000 out-of-pocket limit for Medicare-covered services and select Non-Medicare Supplemental Services. Contact plan for details regarding Non-Medicare Supplemental Services covered under this limit. |
| $750 annual deductible. Contact the plan for services that apply. |
| Any annual service category deductible may count towards the plan level deductible if there is one. |
| $10 000 out-of-pocket limit for Medicare-covered services and select Non-Medicare Supplemental Services. Contact plan for details regarding Non-Medicare Supplemental Services covered under this limit. |
| Doctor and Hospital Choice |
| No referral required for network doctors specialists and hospitals. |
| You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits. |
| Plan covers you when you travel in the U.S. or its territories. |
| ** Inpatient Care ** |
| Inpatient Hospital Care |
| No limit to the number of days covered by the plan each hospital stay. |
| For Medicare-covered hospital stays: |
- Days 1 - 5: $320 copay per day
|
| Days 6 - 90: $0 copay per day |
| $0 copay for additional hospital days |
| Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
| For hospital stays: |
- Days 1 - 27: $495 copay per day
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| Days 28 - 90: $0 copay per day |
| Inpatient Mental Health Care |
| You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. |
| For Medicare-covered hospital stays: |
- Days 1 - 5: $285 copay per day
|
| Days 6 - 90: $0 copay per day |
| Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
| For hospital stays: |
- Days 1 - 27: $495 copay per day
|
| Days 28 - 90: $0 copay per day |
| Skilled Nursing Facility (SNF) |
| Authorization rules may apply. |
| Plan covers up to 100 days each benefit period |
| No prior hospital stay is required. |
| For Medicare-covered SNF stays: |
- Days 1 - 20: $50 copay per day
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| Days 21 - 58: $100 copay per day |
| Days 59 - 100: $0 copay per day |
| For each SNF stay: |
- Days 1 - 58: $250 copay per SNF day
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| Days 59 - 100: $0 copay per SNF day |
| Home Health Care |
| $0 copay for Medicare-covered home health visits |
| 50% of the cost for Medicare-covered home health visits |
| Hospice |
| You must get care from a Medicare-certified hospice. Your plan will pay for a consultative visit before you select hospice. |
| ** Outpatient Care ** |
| Doctor Office Visits |
| $10 copay for each Medicare-covered primary care doctor visit. |
| $45 copay for each Medicare-covered specialist visit. |
| $40 copay for each Medicare-covered primary care doctor visit |
| $50 copay for each Medicare-covered specialist visit |
| Chiropractic Services |
| $10 to $20 copay for each Medicare-covered chiropractic visit |
| Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor. |
| $50 copay for Medicare-covered chiropractic visits. |
| Podiatry Services |
| $45 copay for each Medicare-covered podiatry visit |
| $45 copay for up to 6 supplemental routine podiatry visit(s) every year |
| Medicare-covered podiatry visits are for medically-necessary foot care. |
| $50 copay for Medicare-covered podiatry visits |
| $50 copay for supplemental routine podiatry visits |
| Outpatient Mental Health Care |
| $40 copay for each Medicare-covered individual therapy visit |
| $40 copay for each Medicare-covered group therapy visit |
| $40 copay for each Medicare-covered individual therapy visit with a psychiatrist |
| $40 copay for each Medicare-covered group therapy visit with a psychiatrist |
| $40 copay for Medicare-covered partial hospitalization program services |
| $40 copay for Medicare-covered Mental Health visits with a psychiatrist |
| $40 copay for Medicare-covered Mental Health visits |
| 40% of the cost for Medicare-covered partial hospitalization program services |
| Outpatient Substance Abuse Care |
| $40 copay for Medicare-covered individual substance abuse outpatient treatment visits |
| $40 copay for Medicare-covered group substance abuse outpatient treatment visits |
| $40 copay Medicare-covered substance abuse outpatient treatment visits |
| Outpatient Services |
| $275 copay for each Medicare-covered ambulatory surgical center visit |
| $15 to $50 copay [or 20% of the cost] for each Medicare-covered outpatient hospital facility visit |
| 40% of the cost for Medicare-covered outpatient hospital facility visits |
| 40% of the cost for Medicare-covered ambulatory surgical center visits |
| Ambulance Services |
| $250 copay for Medicare-covered ambulance benefits. |
| $250 copay for Medicare-covered ambulance benefits. |
| Emergency Care |
| $65 copay for Medicare-covered emergency room visits |
| Worldwide coverage. |
| If you are immediately admitted to the hospital you pay $0 for the emergency room visit. |
| Urgently Needed Care |
| $40 copay for Medicare-covered urgently-needed-care visits |
| Outpatient Rehabilitation Services |
| $45 copay for Medicare-covered Occupational Therapy visits |
| $45 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits |
| $50 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits |
| $50 copay for Medicare-covered Occupational Therapy visits. |
| ** Outpatient Medical Services and Supplies ** |
| Durable Medical Equipment |
| 10% to 15% of the cost for Medicare-covered durable medical equipment |
| 30% of the cost for Medicare-covered durable medical equipment |
| Prosthetic Devices |
| 20% of the cost for Medicare-covered prosthetic devices |
| 40% of the cost for Medicare-covered prosthetic devices. |
| Diabetes Programs and Supplies |
| $0 copay for Medicare-covered Diabetes self-management training |
| $0 copay for Medicare-covered: |
- Diabetes monitoring supplies
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| Therapeutic shoes or inserts |
| 40% of the cost for Medicare-covered Diabetes self-management training |
| 30% of the cost for Medicare-covered Diabetes monitoring supplies |
| 30% of the cost for Medicare-covered Therapeutic shoes or inserts |
| Diagnostic Tests, X-Rays, Lab Services, and Radiology Services |
| Authorization rules may apply. |
| $0 copay for Medicare-covered lab services |
| $0 to $75 copay for Medicare-covered diagnostic procedures and tests |
| $10 to $75 copay [or 20% of the cost] for Medicare-covered X-rays |
| $125 copay [or 20% of the cost] for Medicare-covered diagnostic radiology services (not including X-rays) |
| $45 copay [or 20% of the cost] for Medicare-covered therapeutic radiology services |
| If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of $10 to $45 may apply |
| If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $10 to $45 may apply |
| 40% of the cost for Medicare-covered therapeutic radiology services |
| 40% of the cost for Medicare-covered outpatient X-rays |
| 40% of the cost for Medicare-covered diagnostic radiology services |
| 40% of the cost for Medicare-covered diagnostic procedures tests and lab services |
| ** Preventive Services ** |
| Cardiac and Pulmonary Rehabilitation Services |
| $50 copay for Medicare-covered Cardiac Rehabilitation Services |
| $50 copay for Medicare-covered Intensive Cardiac Rehabilitation Services |
| $50 copay for Medicare-covered Pulmonary Rehabilitation Services |
| $50 copay [or 40% of the cost] for Medicare-covered Cardiac Rehabilitation Services |
| $50 copay [or 40% of the cost] for Medicare-covered Intensive Cardiac Rehabilitation Services |
| $50 copay [or 40% of the cost] for Medicare-covered Pulmonary Rehabilitation Services |
| Preventive Services and Wellness/Education Programs |
| $0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. |
| The plan covers the following supplemental education/wellness programs: |
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| Health Club Membership/Fitness Classes |
| Nursing Hotline |
| 40% of the cost for Medicare-covered preventive services |
| $0 copay for supplemental education/wellness programs |
| Kidney Disease and Conditions |
| 20% of the cost for Medicare-covered renal dialysis |
| $0 copay for Medicare-covered kidney disease education services |
| 40% of the cost for Medicare-covered kidney disease education services |
| 20% of the cost for Medicare-covered renal dialysis |
| Outpatient Prescription Drugs |
| $5 copay [or 20% of the cost] for Medicare Part B chemotherapy drugs and other Part B drugs. |
| 50% of the cost for Medicare Part B drugs out-of-network. |
| This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.myprime.com on the web. |
Different out-of-pocket costs may apply for people who - have limited incomes
- live in long term care facilities or
- have access to Indian/Tribal/Urban (Indian Health Service) providers.
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| The plan offers national in-network prescription coverage (i.e. this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan’s service area (for instance when you travel). |
| Total yearly drug costs are the total drug costs paid by both you and a Part D plan. |
| The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. |
| Some drugs have quantity limits. |
| Your provider must get prior authorization from BlueMedicare Regional PPO (Regional PPO) for certain drugs. |
| You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan’s website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. |
| If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount. |
| If you request a formulary exception for a drug and BlueMedicare Regional PPO (Regional PPO) approves the exception you will pay Tier 4: Non-Preferred Brand cost sharing for that drug. |
| $0 deductible. |
| You pay the following until total yearly drug costs reach $2 970: |
| Tier 1: Preferred Generic |
| Tier 2: Non-Preferred Generic |
| Tier 3: Preferred Brand |
| Tier 4: Non-Preferred Brand |
| Tier 5: Specialty Tier |
- $6 copay for a one-month (31-day) supply of drugs in this tier
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| $10 copay for a one-month (31-day) supply of drugs in this tier |
| $45 copay for a one-month (31-day) supply of drugs in this tier |
| $95 copay for a one-month (31-day) supply of drugs in this tier |
| 33% coinsurance for a one-month (31-day) supply of drugs in this tier |
| $18 copay for a three-month (90-day) supply of drugs in this tier |
| $30 copay for a three-month (90-day) supply of drugs in this tier |
| $135 copay for a three-month (90-day) supply of drugs in this tier |
| $285 copay for a three-month (90-day) supply of drugs in this tier |
| 33% coinsurance for a three-month (90-day) supply of drugs in this tier |
| Tier 1: Preferred Generic |
| Tier 2: Non-Preferred Generic |
| Tier 3: Preferred Brand |
| Tier 4: Non-Preferred Brand |
| Tier 5: Specialty Tier |
- $6 copay for a one-month (31-day) supply of drugs in this tier
|
| $10 copay for a one-month (31-day) supply of drugs in this tier |
| 33% coinsurance for a one-month (31-day) supply of drugs in this tier |
| $45 copay for a one-month (31-day) supply of drugs in this tier |
| $95 copay for a one-month (31-day) supply of drugs in this tier |
| Please note that brand drugs must be dispensed incrementally in long-term care facilities. Generic drugs may be dispensed incrementally. Contact your plan about cost-sharing billing/collection when less than a one-month supply is dispensed. |
| Tier 1: Preferred Generic |
| Tier 2: Non-Preferred Generic |
| Tier 3: Preferred Brand |
| Tier 4: Non-Preferred Brand |
| Tier 5: Specialty Tier |
- $0 copay for a one-month (31-day) supply of drugs in this tier
|
| $5 copay for a one-month (31-day) supply of drugs in this tier |
| $45 copay for a one-month (31-day) supply of drugs in this tier |
| $95 copay for a one-month (31-day) supply of drugs in this tier |
| 33% coinsurance for a one-month (31-day) supply of drugs in this tier |
| $0 copay for a three-month (90-day) supply of drugs in this tier |
| $15 copay for a three-month (90-day) supply of drugs in this tier |
| $135 copay for a three-month (90-day) supply of drugs in this tier |
| $285 copay for a three-month (90-day) supply of drugs in this tier |
| 33% coinsurance for a three-month (90-day) supply of drugs in this tier |
| After your total yearly drug costs reach $2 970 you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 47.5% for the plan’s costs for brand drugs and 79% of the plan’s costs for generic drugs until your yearly out-of-pocket drug costs reach $4 750. |
After your yearly out-of-pocket drug costs reach $4 750 you pay the greater of: - 5% coinsurance or
- $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copay for all other drugs.
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| Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan’s service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy’s full charge for the drug and submit documentation to receive reimbursement from BlueMedicare Regional PPO (Regional PPO). |
| You will be reimbursed up to the plan’s cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 970: |
| Tier 1: Preferred Generic |
| Tier 2: Non-Preferred Generic |
| Tier 3: Preferred Brand |
| Tier 4: Non-Preferred Brand |
| Tier 5: Specialty Tier |
- $6 copay for a one-month (31-day) supply of drugs in this tier
|
| $10 copay for a one-month (31-day) supply of drugs in this tier |
| $45 copay for a one-month (31-day) supply of drugs in this tier |
| $95 copay for a one-month (31-day) supply of drugs in this tier |
| 33% coinsurance for a one-month (31-day) supply of drugs in this tier |
| You will be reimbursed up to 21% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 750. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). You will be reimbursed up to 52.5% of the plan allowable cost for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4 750. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). |
After your yearly out-of-pocket drug costs reach $4 750 you will be reimbursed for drugs purchased out-of-network up to the plan’s cost of the drug minus your cost share which is the greater of: - 5% coinsurance or
- $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copay for all other drugs.
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| Dental Services |
| $0 copay for the following preventive dental benefits: |
- up to 2 oral exam(s) every year
|
| up to 1 cleaning(s) every year |
| up to 1 dental x-ray(s) |
| $45 copay for Medicare-covered dental benefits |
| 40% to 50% of the cost for Medicare-covered comprehensive dental benefits |
| 40% to 50% of the cost for supplemental comprehensive dental benefits |
| 40% to 50% of the cost for supplemental preventive dental benefits |
| Contact the plan for availability of additional in-network and out-of-network comprehensive dental benefits. |
| Hearing Services |
| $0 copay for up to 2 hearing aid(s) every three years |
| $45 copay for Medicare-covered diagnostic hearing exams |
| $0 copay for up to 1 supplemental routine hearing exam(s) every year |
| $0 copay for up to 1 hearing aid fitting-evaluation(s) every year |
| $50 copay for Medicare-covered diagnostic hearing exams. |
| $0 copay for supplemental hearing exams. |
| $0 copay for supplemental hearing aids. |
| $1 000 plan coverage limit for supplemental routine hearing aids every three years. This limit applies to both in-network and out-of-network benefits. |
| ** Additional Benefits ** |
| Vision Services |
| Authorization rules may apply. |
- $0 copay for one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery.
|
| $0 to $45 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye. |
| $0 copay for up to 1 supplemental routine eye exam(s) every year |
| $20 copay for up to 1 pair(s) of contacts every two years |
| $20 copay for up to 1 pair(s) of lenses every two years |
| $20 copay for up to 1 frame(s) every two years |
| $110 plan coverage limit for contact lenses every two years. |
| $100 plan coverage limit for eye glass frames every two years. |
| $50 copay for Medicare-covered eye exams |
| $0 copay for supplemental eye exams |
| $50 copay for Medicare-covered eye wear |
| $20 copay for supplemental eye wear |
| The plan will pay up to $125 for all of the following services combined: Supplemental |
| $110 plan coverage limit for contact lenses every two years. This limit applies to both in-network and out-of-network benefits. |
| $100 plan coverage limit for eye glass frames every two years. This limit applies to both in-network and out-of-network benefits. |
| Over-the-Counter Items |
| The plan does not cover Over-the-Counter items. |
| Transportation |
| This plan does not cover supplemental routine transportation. |
| Acupuncture |
| This plan does not cover Acupuncture. |
| ** Inpatient Care ** |
| Inpatient Hospital Care |
| No limit to the number of days covered by the plan each hospital stay. |
| For Medicare-covered hospital stays: |
- Days 1 - 5: $320 copay per day
|
| Days 6 - 90: $0 copay per day |
| $0 copay for additional hospital days |
| Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
| For hospital stays: |
- Days 1 - 27: $495 copay per day
|
| Days 28 - 90: $0 copay per day |
| ** Outpatient Care ** |
| Doctor Office Visits |
| $10 copay for each Medicare-covered primary care doctor visit. |
| $45 copay for each Medicare-covered specialist visit. |
| $40 copay for each Medicare-covered primary care doctor visit |
| $50 copay for each Medicare-covered specialist visit |
| Outpatient Services |
| $275 copay for each Medicare-covered ambulatory surgical center visit |
| $15 to $50 copay [or 20% of the cost] for each Medicare-covered outpatient hospital facility visit |
| 40% of the cost for Medicare-covered outpatient hospital facility visits |
| 40% of the cost for Medicare-covered ambulatory surgical center visits |
| Ambulance Services |
| $250 copay for Medicare-covered ambulance benefits. |
| $250 copay for Medicare-covered ambulance benefits. |
| ** Outpatient Medical Services and Supplies ** |
| Durable Medical Equipment |
| 10% to 15% of the cost for Medicare-covered durable medical equipment |
| 30% of the cost for Medicare-covered durable medical equipment |
| Diagnostic Tests, X-Rays, Lab Services, and Radiology Services |
| Authorization rules may apply. |
| $0 copay for Medicare-covered lab services |
| $0 to $75 copay for Medicare-covered diagnostic procedures and tests |
| $10 to $75 copay [or 20% of the cost] for Medicare-covered X-rays |
| $125 copay [or 20% of the cost] for Medicare-covered diagnostic radiology services (not including X-rays) |
| $45 copay [or 20% of the cost] for Medicare-covered therapeutic radiology services |
| If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of $10 to $45 may apply |
| If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $10 to $45 may apply |
| 40% of the cost for Medicare-covered therapeutic radiology services |
| 40% of the cost for Medicare-covered outpatient X-rays |
| 40% of the cost for Medicare-covered diagnostic radiology services |
| 40% of the cost for Medicare-covered diagnostic procedures tests and lab services |
| ** Additional Benefits ** |
| Over-the-Counter Items |
| The plan does not cover Over-the-Counter items. |
| Transportation |
| This plan does not cover supplemental routine transportation. |
